Medical Ethics with Annotations Applicable to Addiction Medicine

https://www.asam.org/advocacy/find-a-policy-statement/view-policy-statement/public-policy-statements/2019/01/24/medical-ethics-with-annotations-applicable-to-addiction-medicine

Comment; Good ethical guidelines for all of us to follow. Why don’t insurance companies, government agencies and others have to abide by the same rules that physician are supposed to follow?

Adoption Date:January 23, 2019

Public Policy Statement on Medical Ethics with Annotations Applicable to Addiction Medicine

PDF

Background

All physicians should adhere to the code of medical ethics set forth in the Principles of Medical Ethics of the American Medical Association (AMA). The AMA Principles establish general guidelines for ethical physician practice, but do not address in detail some of the specific ethical responsibilities unique to the practice of addiction medicine. Because of factors such as legal consequences associated with drug use, limited treatment options available to many patients, and stigmatization of patients with addiction, addiction medicine specialists face professional ethical challenges that colleagues in other medical specialties do not. This document aims to adhere to the basic AMA Principles of Medical Ethics with annotations to help guide the ethical decision-making of those clinicians practicing addiction medicine. [i] 

Principles and Annotations

Section 1

A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.

• Addiction medicine specialists must be cautious to maintain the appropriate boundaries of a clinician-patient relationship and be cognizant of how their actions may impact that relationship and ultimately the well-being of the patient. While some addiction medicine specialists are themselves in recovery, as treating providers they should be cautious about self-disclosure and the effect that may have on the clinician-patient relationship. As a general principle, the decision to disclose personal information should be evaluated from the perspective of the extent to which it is helpful to the patient.
• An addiction medicine specialist must be cautious and should disclose to the patient when practicing outside his or her area(s) of professional expertise, as might be the case when a patient cannot access another clinician with specialty training most pertinent to a presenting problem.
• In some cases, addiction treatment is mandated, offered as an alternative to criminal justice or other sanctions, or provided involuntarily to intoxicated individuals who cannot make reasoned decisions for themselves. In these cases, the addiction medicine specialist must take special care to advocate on behalf of the patient’s best interest and promote patient autonomy.
• Addiction medicine specialists should aspire to provide person-centered care to each patient and should not abandon a patient solely because the patient disagrees with the treatment plan or fails to progress or experiences a setback in treatment. 

Section 2 

A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to advocate for patients, even when that involves reporting a colleague who is not competent, is impaired or engages in fraud or deception.

• Addiction medicine specialists should seek to be free of financial conflicts of interest and should prioritize the wellbeing of their patients above financial gain for themselves or their employers.
  • Addiction medicine specialists who oversee patient care and review treatment plans as part of their responsibilities should decline to approve treatment plans that do not comport with the available evidence base for addiction treatment.  Business interests should not take priority over a patient’s clinical needs when determining a treatment plan. This includes the inappropriate use and over use of ancillary studies such as neuroimaging and toxicology.
  •  Addiction medicine specialists should report treatment outcomes accurately, thereby providing valuable data to inform the evidence base and promote the social good.
• Addiction medicine specialists should make independent decisions in setting fees for their clinical services, but should strive to ensure such fees are not exploitative.
• Addiction medicine specialists are aware that impaired practice by a colleague may result from illness, including the illness of addiction, and have a duty to help encourage that clinician’s treatment and recovery. Where there are laws mandating that clinicians report impaired colleagues to licensing boards, clinicians should abide by those laws.
• Where law allows referral of a physician to a state physician health program, this non-disciplinary route to diagnosis and treatment should be offered.  An impaired clinician’s confidentiality should be respected, especially when the impaired clinician is a patient, but the need to protect confidentiality should be balanced against public safety.

Section 3 

A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.

• The criminalization of the symptoms of addiction often leads to consequences and sanctions which are contrary to the best interests of the patient. Consistent with ASAM’s longstanding policy supporting treatment rather than incarceration for persons with addiction, clinicians should support changes to federal and state laws to promote screening and treatment for those with addiction and support recovery rather than penalize relapse. 
• Addiction medicine specialists should support changes to laws that require reporting of pregnant women who use substances, as such laws discourage women from seeking addiction treatment and prenatal care, which can lead to worse health outcomes for mother and infant.
• Addiction medicine specialists should support changes to laws that limit patients’ access to treatment, including laws and regulations that prohibit the availability of evidence-based treatment in criminal justice settings or the implementation of evidence-based harm reduction interventions.

Section 4 

A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law.

• Like all medical records, addiction treatment records, including the identification of a person as a patient receiving addiction treatment, must be protected with extreme care, as confidentiality is critical to a trusting and successful treatment relationship between the addiction medicine clinician and patient.
• Addiction medicine specialists should not give legal advice but should support patients in seeking legal counsel if needed.
• Decisions about treatment, referral, and reporting of patients should be made based solely on medical evidence and in accordance with applicable laws, and should not be influenced by a patient’s race, ethnicity, religion, immigration status, age, gender, gender identity, sexual orientation, socioeconomic status, or other personal or demographic characteristics that are independent of a patient’s medical status and treatment needs.

Section 5 

A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated.

• The addiction medicine specialist should be aware of the sponsor(s) of all continuing medical education (CME) courses and should seek professional training opportunities that are free from conflict or other bias.

Section 6 

A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.

• Addiction medicine specialists should be cautious when considering whether to provide treatment to colleagues, acquaintances, family members and friends. Professional judgement may be compromised when caring for patients with whom the clinician has a personal relationship and patients may worry about bias or lack of confidentiality. Such treatment is not categorically unethical, as these patients may have no other option to access treatment, but there are dangers and conflicts in these treatment relationships that should be openly discussed.

Section 7 

A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.

• Addiction medicine specialists are obliged to consider and support interventions which reduce risk and morbidity for the community at large. It obliges giving careful consideration to supporting public health measures that reduce harm in a community without necessarily forming definitive treatment (e.g., naloxone distribution, syringe exchange programs).
• This principle has particular application to the responsibility of addiction medicine specialists to support evidence-based community prevention efforts.

Section 8 

A physician shall, while caring for a patient, regard responsibility to the patient as paramount.
Section 9 

A physician shall support access to medical care for all people.

• Addiction treatment should be a component of this care.